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Tuesday, May 31, 2016

ObamaCare
Legacy: The Good, The Bad, and the Ugly

This is
a must read collection of essays that gives the good, the bad, and the ugly of
the new health care law.

Jacket
blurb on my 2011 book,The Health Reform
Maze,by Donald J. Palmisano, MD,
former president of American Medical Association and author of On Leadership

The
Good, the Bad, and the Ugly was the title of 1966 movie starring Clint
Eastwood and Eli Wallach. The film was
called a Spaghetti Western, or Macaroni
Western because it was produced, directed,
and put to music by Italians.The flick
had good guys, bad guys, and ugly guys,
often acting out of character.The good
guys had noble intentions but were cunning, deceitful, and acted unexpectedly:
the bad guys had their good sides; and the ugly guys did brutal things against
defenseless people.

In any event,in my
2011 book, published the year after ObamaCare was passed,I predicted 8 trends :1) the rise and possible fall of ACOs; 2) consolidationat every level of the health system; 3)
bundled payments between hospitals and doctors; 4) decline of private practice;
5) decentralization of care with dominance of local markets; 6) evolution of concierge medicine; 7) the electronic
revolution ; 8) patient involvement in care,

ObamaCare triggered these trends.Now the time has come to evaluate the good,
the bad, and the ugly effects of the health care law.

The
Good
-20 million people have been removed
from the number of insured – 12.7 million in health exchanges and 7.3 million
in Medicaid, reducing the percent of uninsured from 15% to 10%;coverage of those with preexisting conditions
andyoung adults on their parents’ plans
has been assured.

The Bad
-The cost, roughly $ 1 trillion has exceeded
estimatesand raised taxes for all;the administration has failed to deliver on
its promises of cutting premiums,increasing quality, and improving outcomes;premiums will soar 20% or more in 2017 and
quality and outcomes have not significantly changed; 13 to 23 co-ops
established by the administration have failed with more to come;major insurers, led by UnitedHealth have
pulled outof health exchange
markets;widespread physician shortages
have intensified with decreased access to doctors and narrowing of choices of
doctors; somewhere between 10% to 50% ofdoctors are not accepting Medicare, Medicaid, and ObamaCare patients.

The
Ugly- Increasing numbers of middle income
people can no longer affordpremiums,
deductibles, and co-payments; Jonathan Gruber, an MIT economist said by many to
be architect of ObamaCare,has revealed
that the Obama administration knew from the start people would be unable to
keep their doctors and health plans;The VA system, though not part of ObamaCare,has besmirched the reputation of government as
a competent health care managerof large
populations of needy people;despite
two Supreme Court decisions upholding the constitutionality of ObamaCarerecent lower court decisions questioning the
legality ofhospitals that participate
in ACOs to continue to be charitable institutions and the legality of unilateral subsidies for health exchange without House approval has cast a cloud over
the futureof ObamaCare. Good, bad, and
ugly weather lies ahead.

Compared to Donald Trump,I’m a mere twit.I’ve done 1312
tweets and have 67 followers.He’s tweeted 32,100 times, and he has 8.54
million followers.

Donald Trump uses Twitter to keep his name in front of people
every hour of every day.He often
tweets 12 times a day, sometimes more.He’s also on Instagram and Facebook.He uses the power of the social media to agitate, motivate, and promote,
to settle old scores, and start new ones.

By doing so, he keeps his name constantly before voters, foregoes costly, conventional methods and
unleashes free, urgent,and visceral
messages to his followers, many of whom
will retweet them to friends.He uses
tweets to keep alive endless feuds, to stroke egos, to criticize the media.He is the master of pithy putdown and virtuoso of the tweet.

He is known for his direct and indirectslights on his political rivals, for giving
them derogatory nicknames, and for
articulating what his followers are thinking.
Trump is in command of the Art of the Insult and use of nicknames are a concise counterpunch.

Below are 6 of his recent tweets.

·Does President Obama ever discuss the sneak
attack on Pearl Harbor in Japan.Thousands of Americans died.

·I find it offensive Goofy Elizabeth Warren, sometime referred to
as Pocahontas, pretended be Native American to get into Harvard.

·The Inspector General’s report on Crooked
Hillary Clinton is a disaster.Such bad judgment and temperament cannot be
allowed in the W.H.

·The protesters in New Mexico were thugs who were
flying the Mexican flag.The rally
inside was big and beautiful, but outside criminals!

·Crooked Hillary just can’t close deal with
Bernie Sanders.I have knocked out 16 very smart and very good
candidates.Hillary doesn’t have it.

·I broke all-time records for most votes gotten by
Republicans by a lot – and with many
states to go.

Apparently it is difficult for rich person to be modest, or
a modest person to be rich.Whether his
lack of modesty will propel him into the White House remains a billion dollar
question (the cost of a general election campaign), but given his success with Twitter,I wouldn’t bet against him. As Dizzy Dean, the winning St. Louis Cardinals pitcher, said after winning 28 games, "If you can do it, you ain't bragging."

Sunday, May 29, 2016

Saving
Soul of Medicine

I owe
my soul to the company store.

Lyrics
of song,Sixteen Tons, most memorably sung by TennesseeErnie Ford in 1955

Physicians are struggling to save the soul of medicine.They feel they owe their allegiance and skillstopatients, not to the corporations or hospitals, not to CMS (Centers of Medicare, Medicaid, and
ObamaCare), not to the VA, and not to insurers, all of whom set the
rules of payment for roughly half of all Americans and dictates the rules of
patient engagement.

For physicians this struggle poses problems of the soul, defined as the
principles of life, feeling, thought, and action in man, the spiritual and
moral part of man as distinct from the physical part.

Serving
Three Masters

How do you serve three masters, your employer, your government,
and your patients?How do you serve as
the prime deliverer of these services without sacrificing your soul?

At What
Point

At what point, does the profit of your employer or payer
become more important than your desire to give patients the best medicine has
to offer?

At what point, does servicing your own debt (the average
debt of physicians entering practice is about $200,000) become the force that
drives you and compels you to follow the wishes of those who employ you and pay
your bills?

At what point is enough enough?And you feel you must go on my own to serve yourself,
your family,and your patients better?

At what point, do you heed the words of Matthew 16: 26, “What
is a man profited, if he shall gain the whole world and lose his soul.”

Daunting
Dilemmas

These are daunting dilemmas.

The dilemmas involve choices between morals and markets,socialism and capitalism, economic prosperity
and economic stagnation, government control and individual liberty,
idealism and reality.Physicians find themselves between a rock and
hard place, tormented by tortuous ambiguities and convoluted contradictions.

Do you owe your soul to a government health law, designed to cut
your fees to below Medicare, which is 80% below private fees?

Do you owe your soul to your employer, usually an integrated
hospital system or a large medical group, whose profit may depend on how well
you perform and follow directives?

Past
Writings

I have thought about these dilemmas for years, first in a
1988 book And Who Shall Care for the
Sick?The Corporate Transformation of
Medicine in Minnesota, in 2005 in Voices of Health Reform- Interviews with
Health Care Stakeholders at Work: Options for Repackaging American Health Care,
in a 2009 book Obama, Doctor, and Health
Reform: A Doctor Assesses Odds for Success,in 2011 in The Health Reform
Maze: A Blueprint for Physician Practices, and finally in 4300 blogs and
tweets in Med innovation and Health
Reform. Com (2006 to the present).

No Easy
Answers

The answers are not easy.Universal coverage is noble, but it is proving to be unaffordable
when superimposed on the current entrenched system.Given the nature of the federal bureaucracy,
government care is inherently inefficient and interferes with the doctor-patient
relationship.

Anytime government undertakes anything on a massive scale,
it becomes entrenched permanent, and dependent on its constituents.

If you defy the government, elected by popular vote, you are
labeled as unpatriotic or immoral.If
you act in your own self-interest, you are considered greedy and ignoring the collective
interests of the nation.If you do not
accept Medicare, Medicaid, or ObamaCare exchange patients becauseyou cannot afford their reimbursements levels and stay in practice,
you are said to be inhumane and self-serving.

Saving
the Soul of Medicine, the Whyte Way

In 2007, I interviewed David Whyte, an English poet then
living in Washington State.Whyte
earned his living by serving as a consultant to health care corporations, using poetry as
physician soul-saving tool. Whyte believed physicians were losing their souls to
business matters, and he sought to help corporations help physicians regain
their souls.In his heart and soul,
Whyte believed government health care, as practiced in Britain and Canada, was
the answer in physician-soul saving.

Here was his reasoning:

“The health service in
Britain, just as in Canada, has lots of difficulties, but it is astonishingly
cohesive glue for the whole of society. Neither country would ever swap it for
the system we have in the U.S. “
“The National Health Service gives you the sense of being part of a greater
society, that you are not just part of an anthill with people climbing over one
another. There is a social contract that admits to a greater bond with one
another than our ability to pay up. If things go wrong, there is a safety net. “

“Society has made a contract whereby you will be taken care of no matter what
your financial background or particular circumstances; that is an immensely
powerful idea. I'm not sure the conditions would ever be right in the United
States for that to come to pass, because the mindset, the vested powers and the
individual expectations are so different. “

Asconsultant to major health care corporations,
David believed poetry was a potent humanistic weapon for saving souls. By hiring David, corporations sought to escape
fetters of an overly managed and rigid hierarchal pyramid. Corporate leaders sought
to bring humanity to employees and caregivers to render them more creative,
adaptable, and dedicated.Corporate
leaders sought feedback and ideas from
people on care frontlines, for they were true arbiters of quality coupled with
humanity.

When Whyte used that word soul” in the
workplace, he was encouraging physicians to have a sense of participation in
the particular work or the organization, a sense of texture, color, intrigue,
and surprise. For most human beings, that was an important question to ask and an important
journey to follow.

American physicians, particularly those in
heavy managed care areas, he felt, were
losing their souls in the name of profit. How do they regain their souls? He did not mention the soul of corporations or
their need for profit.

Whyte said the soul of medicine was on trial. There was no coherent voice speaking up for
the spirit of medicine, and the spirit of what doctors stand for. The American
Medical Association had not spoken to the soul of medicine.

Doctors, he added, were trained in a hierarchical way. Because people's lives
were at stake, there were always people who know better how to deal with those
vulnerable thresholds of health. Doctors were therefore constantly deferring to
someone else or to the great hierarchy of knowledge throughout the system.

Something Had to Change

Something, he thought, had to change. No one was happy with the
system.He quoted Oscar Wilde who said of a certain person, 'He has no enemies
but is intensely disliked by all his friends." It applied, unfortunately,
to American health care. It was hard to find anyone who will speak up for the
U.S. health system with any enthusiasm.

Whyte noted we had almost 45 million uninsured people.No society could afford to disenfranchise so many
of its members. We were surely approaching a bridge that we would have to cross, where everyone sould have to give up something, somewhere, and that
bridge was probably not too far ahead of
us.

Not Convinced

I am not convinced that the answer to moral
problem of the uninsured lies in universal government coverage. A government system breeds bureaucracy, is
inherently inefficient, discourages innovation, and inevitably involves
rationing with long waiting lists, as exemplified by today’s VA waiting lists.

For these reasons, and because of the impersonal nature andhigher costs of any government system,a dual system is emerging.

One will be an impersonal government-related and run system, like
Medicare, Medicaid, the VA, and ObamaCare.The other will be for patients and physicians, who seek affordable
liberty and choice, personal care, and efficiencies and amenities , beyond the
reach of government. Or there may be a cross-over between systems. Pete Sessions (R) and Dr. Bill Cassidy (R) have just introduced a House bill that allows patients to stay in or leave ObamaCare health exchanges. As premiums and deductibles rise, they can go to a market based system with $2500 in tax credits (plus $1500 for each child) to purchase private insurance or to put their money into health savings accounts.

Perhaps poetry, with its capacity to make the
complex simpleand its power to evoke the best in the human soul and spirit , is the answer.Perhaps computers and the Internet and social
websites will breed efficiencies , promote individual choice, andgive every patient a portable medical record
to carry from doctor to doctor.

But perhaps not.Government and health care corporationshave turned to algorithms and data and
artificial intelligence to manage doctor-patient relationships,but there is nothing poetic about data. Government
and managed care are not poetry,but
bureaucratic prose (regulations and mandates) and prose run mad.

Friday, May 27, 2016

Forgive me.I have a weakness for creating acronyms critical
of well-intentioned but misguided government interventions into the health
system.

W. Edwards Deming (1900-1993),
a statistician, was famous for saying, “In God we trust, and all others use
data.”Deming was referring to data as
the only reliable way to measure quality and gauge continuous improvement.

His statement was a forerunner
of the current measurement craze over algorithmic data as the best and only
means of controlling health care quality and containing costs.This management mindset has popularized and
characterized the movement towards evidence-based care, pay-for-performance pay
for physicians, and data-based population health as the way to improve outcomes
and decrease costs.

This movement has met resistance
among physicians, who insist you can’t judge physicians by numbers alone, and
patients, who would rather not have the details of their care and illnesses
exposed to the world through personal data exposure to the government or
anybody else.

A study of electronic records
by the California Health Association of 1587 adults found that 15% said they
would lie to conceal information “if the doctor had an electronic record,” and
another 33% would “consider hiding information .” Another study , conducted by
GE, the Cleveland Clinic, and Oshner Health System said 13% of patients fibbed
about exercise,9% about diets,9% about taking their medicine,7% about drinking,7% about smoking,4% about taking illegal drugs, and 4% about unprotected sex
(Medinnovation and Heath Reform,“Survey;
Patients May Lie if Electronic Records Are Shared,” April 17, 2010),

Which brings me to the news of
the day.Kaiser Health News reports that A 41 year old psychiatrist says 55%
of psychiatrists now charge patients directlyrather going through 3rd parties
(“A Doctor Yearns for a Return to the Time When Physicians Were Artisans” and “Doctor
House Calls Saving Medicare Money.”Doctors and patients alike are seeking more private, personal, home, decentralized,
confidential care based on mutual trust, outside the reach
of electronic health records.

The Good Old Days are , of course, unlikely to return, given the
penchant for the importance of time
spent documenting over time spent doctoring.Asgovrnment continues to cutprovide pay,doctor consolidationwill roll on over the next decade, and
federal and private insurers will insist on datarather than on trust between doctors and
patients to do the right thing.“The
future “, as Yogi Berra noted,” ain’t what it used to be.”

However, there’s a search
out there for more personal care, based on trust between patient and doctor without
intrusion by data-seeking computers.Patients want refugefrom
thedigital revolution, where nothing is
hidden and everything is known about the personal habits,illness details, financial status, and health
care shopping patterns of patient.Doctors are seeking to escape from expenses, irritations,and delays of hasslesand prohibitive overheads imposed by 3rd
parties,Patients yearn for a more trusting
, confidential relationship between them and their doctors and more eye-to-eye
contact with a personal doctor, absent an interposed computer, recording every
detail of the encounter.Total transparency is overrated .Some things should be kept private

MemorialDay
commemorates veterans killed in defendingAmerica.Memorial Daycelebrations depends onhistorical knowledge – on a sense of history of America’s wars –
the Revolutionary War, the Civil War,World War I, World War II,the
Korean War, the Vietnam War, the
Afghanistan and Iraq Wars,and Yes, oncurrent
conflicts against ISIS, which has yet to be called a War.

The
Young and Knowledge of History

Yet, if you listen to
young people being interviewed on the streets,they have little knowledge of
history.They have no sense of when
these wars were fought,who the
combatants were, what issues led to the
conflicts,and what the economic consequences
were.History has lessons to teach, but
they seem unaware of them.

Thisis too bad.As Abraham Lincoln intoned in its 1862
Annual Message to Congress, “Fellow citizens, we cannot escape history. We of
this Congress and this administrationwill be remember in spite of ourselves. No personal significance or
insignificance can spare one or another of us.” History has legacies.

This warning applies particularly to the young, aged 18 to 34, who are now the largest voting demographic
segment of the U.S. population.

How
Will History Judge Clinton, Sanders, and Trump

How do millenials think history will judge the policies of Hillary
Clinton,the status quo of the last eight years, whichhas featured withdrawalfrom the Middle East wars with attendant uptickin chaos and terrorism, and a stagnant economy?

Will the failed histories ofsocialistic economiesbe repeated in the promises of Bernie Sanders,whose idealism favors government control over
individualliberties,with “free” health care and college tuitions
for all ?

Will Donald Trump prevail, with his capitalistic promises ofmaking America great again, bynegotiating deals favorable to America, by wiping outthe deficit,and by declaring war
on ISIS andradical Islam?

Is
Government Up to the Job

Is government under
any of these leaders up to the job of controllingwars,restoring
social justice,andguaranteeing peace?

Big government has not proven it can manage economic failure.It cannot keep within a budget when it comes
to cutting back on“free”
entitlements.It seldom abandons a project if it conflicts
with its ideology.It is not gambling
with its own money, butthat of the taxpayer.Its success is measured in good intentions,
not results.It succeeds by growing
too big to fail and too influential to stop.It can’t go out of business, can print money to keep going , and is
propped up by taxpayer money. It has not
proven effective in avoiding wars or terrorist outbreaks.And it failed to restore economic growth

Until
Now

At least until now.Now we have populist uprisings against
government on both the left and the right because its self-serving corruption and its failures to deliver on its promises.

Only history will tellif government,as now constituted
and now controlled by the Establishment,is up to the job of avoiding wars,
keeping the peace,restoring prosperity, and expanding affordable
health care? .

Wednesday, May 25, 2016

The
Status Is Longer Quo: What It’s All About and Where It’s All Headed?

A physician friend asked what to expect in the near future.

I said, ”The status is no longer quo.”

”What does that mean,” he replied , where are we headed, and
where does that leave me?”

It meansthe
information age has turned the world of politics and the world of health care
upside downand downside up.

Uprooted
Political Establishment

It means the traditional political establishment , which has
shaped health care policy in the past,is being uprooted.No matter who
gets elected, it is likely that the individual and employer mandates will soon
be gone and that electronic health records and physician payment policieswillbe
altered.

It is now apparent that ObamaCare doesn’t lower costs,limits choice, and makes premiums,
deductibles, and co-pays unaffordable for most of the unsubsidized middle class.The middle class is mad as hell and may turn
out in droves to do something about their economic plight and about perceived
political corruption at high levels of government.

It means things are in flux.It means things will never be the same again.

On the
Social Scene

On the social scene,it means minorities and elites are threatening to become the majority.It means blacks, thanks to a black president,
will continue to vote as a solid
block.It means white male workerswill also vote en mass the other wwyal It means concern for the future exceeds
nostalgia for the past.

It means a resurgence
in national pride,middle class angst,
and the silent majority.It means more
social unrest, with increases in crimeand declines in morality.It means
anger among workers who have been
displaced by the global economy and the information technology revolution.It means a realignment of our culture, with
more emphasis on identity politics, whether you’re black, white, Hispanic,
Oriental, Islamic, mixed, homosexual, female, white male, or veteran.

On the
Medical Scene

On the medical scene,it means a clash between data algorithms and human rhythms and desires.It meansthe emergence of possible ObamaCare alternatives,such as market-based competitive care backed
by Republicans.And, at the same time, it
means a call for possible universal care as
advocated byBernie Sanders and the
millenials.It means young physicians,
in search of economic security and a balanced life style,will go for hospital employmentor higher paid specialties .

It means two
simultaneous movements are occurring ,more hospital and big group
consolidation,and more care outside of
hospitals in more private, personal , focused care, and concierge settings.

It meansmore home care,more IT monitoring of chronically ill patients
in their homes,and more home care visits. It means significant
numbers of patients will delay physician visits,seek alternative medical options,treat themselves, or not take medications
are prescribed.Care will be
delayed,symptoms and illnesses will be
neglected,and care, when required, will
be more expensive.

On the positive side,it may mean people will concentrate more on prevention,seek to stay fit,monitor their fitness with electronic devices,eat the proper foods, maintain a normal weigh,
smoke less,and avoidexcessive alcohol consumption and addictive
drug an pot use. And at the federal level, it may mean medical scientists at the National Institutes of Health, though genetic manipulation and immunotherapy, will finally find effective ways to combat and cure multiple types of cancers.

Tuesday, May 24, 2016

Observations
of and on Richard “Buz”Cooper

In January of this
year,Richard “Buz” Cooper, MD,a renowned oncologist and health care
analyst, died of pancreatic cancer.Cooper was known for this straight talk.He believed poverty and delayed treatment
for the poor was a major cause for high health costs, not physicians overuse
of care engendered driven by fee-for-service.

I had the privilege of
knowing Doctor Cooper and wrote the
following blogs on his work.I have edited them for brevity but sought to
retain the essence of the man.

Doctors Don't Drive Up Costs: Poverty Does

I am
a big fan of Richard “Buz” Cooper, MD, Professor of Medicine and Senior Fellow in the
Leonard Davis Institute of Health Economics at the University of
Pennsylvania.

He is afine, clear, and direct writer.

He firmly grasps
what drives up health costs.

Recently Dr. Cooper
made a presentation before an audience of physician workforce consultants at
Merritt Hawkins,and I could not resist
reprinting this piece by Phillip Miller, VP of communications at Merritt
Hawkins, the national physician recruiting firm.

Cooperturns the conventional wisdom of elite policy
wonks on its head by saying, in essence, it isn't“overdoctoring” that drives up costs; it’s
sick poor patients who show up in the later stages of their illnesses in
economically unstable partsof the
country – like the American South,remote rural areas, andinner urban cities.

For Cooper, poverty and economic instability
is a short, simple, and reasonable explanation for cost variations across
the U.S.

Do Doctors Really
Drive Up Health Care Costs?

By Phillip Miller

The “experts” are wrong. They are simply flat
wrong.

That’s the only conclusion I believe a
reasonable person can draw after reviewing the data and analysis compiled by
Richard “Buz” Cooper, M.D., an oncologist and an internationally noted
authority on physician supply and health care utilization studies.

Dr. Cooper recently
presented his case before an audience of physician staffing consultants at
Merritt Hawkins.

His topic was current
physician workforce trends, including why there are regional variations in both
physician supply and in health care costs.

The conventional
wisdom is that regional variations in cost are driven by variations in how
physicians practice. Health care is provided relatively inexpensively in the
upper Midwest, the argument goes, because physicians practice efficiently and
keep utilization down.

In other regions, by contrast, physicians
“over-doctor,” driving up costs.
In the run-up to health reform it was repeatedly stated by policy makers and
analysts that $700 billion, 30% of all health care spending, could be saved if physicians would only
practice like they do in the upper Midwest and other low cost regions.

Control how physicians
practice and you can control healthcare spending, is the underlying basis of
much of today’s health care policy.

But as Dr. Cooper
clearly shows statistically, doctors don’t practice more efficiently in the
Midwest. They practice more efficiently in economically stable
parts of the Midwest. They also practice efficiently in economically stable
parts of Manhattan, Los Angeles, and just about everywhere else.

Dr. Cooper observes
health care costs are 82% of the national average in prosperous parts of New
York City. Literally blocks away in less privileged areas, health care costs
are three times the national average per capita, even though the hospitals and
medical staffs serving patients from both areas are the same.

Places where health
care costs are thought to be high, such as much of the Northeast, are actually
comparable to the Midwest and other low costs areas when you compare apples to
apples, i.e., one economically stable population to another.

Poorer people are
sicker and cost more to treat than do more economically stable people by a
large margin. Therefore, the key to lowering health care costs is to reduce
poverty and increase wealth. Standing over the shoulders of physicians telling
them how to practice is not the answer.

This seems like a
straightforward argument, but it is not widely accepted in health policy
circles. The problem of rising health
care costs derived mostly from how physicians practice, or mostly a result of
economics? Or is there another driving force?

Conclusion

The principle driver of variation of health costs is economic
instability and poverty,not physician
“overdoctoring.”

It took me a while to figure out what the Dartmouth authors meant by “Getting
Past Denial.” They never say explicitly what they mean. In effect, the
Dartmouth policy wonks are saying fee-for-service incentives move doctors to
“do more” to maximize profits.

In
another article in the same NEJM edition, Arnold Relman, MD, former editor of
the New England Journal, says it more directly, “Most doctors are paid
on a fee-for-service basis, which is a strong financial incentive for them to
maximize the elective services they provide (“Doctors as the Key to Health Care
Reform,” NEJM, September 24).

Opines
Relman, what we must do to bring down costs and improve quality, is "pay
group physicians a salary for providing patients with the best, most
cost-effective care, within the limits of a publicly determined budget.

Richard “Buz” Cooper, MD, professor of medicine at the University of Pennsylvania
and a senior fellow in the Leonard Davis Institute of Health Economics at Penn.
Cooper has directly challenged the Dartmouth premise and Relman.Cooperdisagrees.Hedoesn’t thin, regional cost differences in the 30% range
stem from overuse of “discretionary resources” by specialists and subspecialists
in high spending regions, but are secondary to poverty and higher spending for
delayed diagnosis and higher spending on sick patients.

Cooper maintains levels of sickness, socioeconomic and cultural differences,
and cost of doing business in different sections of the country must be taken
into account and that Medicare spending is not representative of health care
spending as a whole.

Cooper has issued three reports to this affect, one in association.

• One, “Physicians and Their
Practices Under Health Care Reform: A Report to the President and The
Congress,” prepared on behalf of The Physicians’ Foundation, and distributed to
members of Congress, the White House, and the media, on September 8, 2009.

• Two, “Regional Variation and the
Affluent-Poverty Nexus, Journal of the American Medical Association,
September 9, 2009

30% “Savings”
The differences between the Cooper and Dartmouth and Relman positions are important. Peter Orzag, Obama’s budget director, buys the Dartmouth argument that erasing regional
differences could reduce “waste” by 30%, and generate enough savings to cover
the uninsured.

You may not be aware of the Cooper-Dartmouth debate because Dartmouth has
chosen to cloak its differences with Cooper and followers through euphemistic
language and by not mentioning Cooper by
name. This is an academic put-down.

A perfect example of the Dartmouth approach is in full display in a September
24 NEJM article “Getting Past Denial – The High Cost of Health Care in the
United States. “

The Dartmouth authors never mention Cooper. Indeed, they never explicitly say
what “Getting Past Denial,” means.One
can infer what they mean when they when they talk of overuse of “discretionary
resources ” by doctors “who have succumbed to behavioral bias.” I would argue
“behavioral bias” effects everyone, wonks as well as practitioners. As George
Orwell famously said, “ no one is genuinely free of political bias.”

From their figures and tables, however, what Dartmouth means is clear. After
admitting that health status and income may be minor Medicare factors, they
move to their statistical "Quintile" argument.

In one figure, “Quintiles of Care Intensity,” a colorful bar graph shows that
“regional factors” have 5 to 20 times more impact than health, income, and race
on costs in annual per capita regional Medicare spending from the least to most
intensive quintiles.

In a table, the Dartmouth triumvirate shows these differences as one moves from
intensity quintiles 1 to 5: impatient days per beneficiary, 1.4 to 2.1 days, up
50%; physician visits per beneficiary, 10.7 to 14.5 days, up 35%; MRI use per
100 beneficiaries, 16.6 to 21.9; CT scans per 100 beneifciaries, 46.9 to 61.4,
a 31% increase.

The Dartmouth authors conclude, “We should recognize that so much discretionary
care is provided in the United States that we would easily expand coverage
without increases in taxes or rationing care – as long as we couple coverage
expansion and broadly implementing successful reforms in payment and delivery
systems.”

Presumably these reforms entail progressing towards integrated salaried group
practices operating on a capitated basis without fee-for-service incentives ,
through they never say so. That would be too direct and impolite. Instead
readers are subjected to a high-level hatchet job questioning the integrity and
motives of physicians in high-spending Medicare regions

I would
like to bring to your attention three reports by Richard “Buz” Cooper, MD,
professor of medicine and principal of the Leonard Davis Institute of Health
Economics at the University of Pennsylvania.

• One, “Physicians and Their
Practices Under Health Care Reform: A Report to the President and The
Congress,” prepared on behalf of The Physicians’ Foundation, and distributed to
members of Congress, the White House, and the media, on September 8, 2009.

• Two, “Regional Variation and the
Affluent-Poverty Nexus, Journal of the American Medical Association,
September 9, 2009.

These reports come at an opportune time in the wake of these events: President
Obama’s speech before Congress on September 9; his campaign stops across the
country to rally his followers, the first today in Minneapolis; the taxpayer
march on Washington today of 100,000 people ; and 10,000 physicians assembling
in D.C. the same day to protest Obama health care policies. These events follow
the raucous town hall meetings of August.

The Physicians Foundation

I believe Dr. Cooper’s report before Congress. supported by The Physicians
Foundation, a 501C3 non-profit organization representing 650,000 practicing
physicians in state and local medical societies, lends perspective, context,
and rationality to the otherwise emotional debate over health care.

Contents of Three Cooper Reports

Perhaps the objective way to present the contents of Dr. Cooper’s three reports
is to use his words summing up their contents.

• One, the “Cooper Report,“ to the
President and Congress is a 53 page document. Here are Dr. Cooper’s words about
its contents with a list of its other authors,

“Our report is intended to inform the discussions of health care reform
about the deepening physician shortages, the needs of physicians' practices in
a reformed health care system and the effects of poverty and other social
determinants on health care utilization and outcomes. Its conclusions are that,
without adequate numbers of physicians, the health care system cannot function;
without adequate attention to the structure of physician practices, the system
cannot function efficiently; and without adequate attention to the pervasive
effects of poverty and other social determinants, it cannot function
economically.”

“ We hope you will find this to be useful as the critical issues that it
addresses are discussed in the months ahead.

Second,
it demonstrates that when total expenditures rather than expenditures from
Medicare or any single source are considered, regions with more health care
inputs have better aggregate outcomes.

Third,
it suggests that while health care reform has the potential to narrow regional
differences in wealth and health care resources, a substantial degree of
variation is likely to continue for many decades. Fourth, it provides evidence
of the high costs borne by the health care system because of poverty and its
associated social determinants."

“As the United States confronts difficult fiscal choices, there should be no
illusion about the relationship among physician supply, health care spending,
and outcomes. Nor should there be uncertainty about how poverty affects health
care utilization. The reality is that more is more and that poverty leads to
less, and the false assertion that "more is less" should not detract
from efforts to ensure that the United States will have an adequate supply of
physicians for the future.“

• Three, excerpts from the September
11 Washington Post Op-Ed piece.
“President Obama pledged on Wednesday that ‘reducing the waste and inefficiency
in Medicare and Medicaid would pay for most’ of his health-care plan. This
echoes remarks from Peter Orszag, his director of the Office of Management and
Budget, who has claimed that one-third of health-care spending, more than $700
billion, is wasted annually.”

“Those Orszag comments come straight from the Dartmouth Atlas, which announced
that the United States could save 30 percent of its health-care expenditures if
high-spending regions were more like low-spending ones. But this can't be how
we'll pay for reform. The numbers are too good to be true.”

“Orszag has argued that if Medicare spending could be as low in Newark as it is
at Mayo, the nation could save billions. But this theory doesn't hold up in
practice.

Consider:
One-fourth of the folks in Newark live in poverty, compared with less than 10
percent of those in Rochester. And national surveys show that poor people
consume more health-care resources -- 50 to 75 percent more than average.

They
are sicker and they stay sicker, despite the best efforts of physicians and
hospitals. Mayo is a fine institution, but it isn't more cost-effective than
other hospitals in its home region, nor are its operations in Jacksonville, Fla.,
and Phoenix more cost-efficient than other hospitals in those cities. So why
would it be more cost-effective in Newark?”

“To really achieve health-care reform, and find a way to pay for it, the
president will have to give up on the Dartmouth suggestion and grapple with
some painful truths.

First,
medical care is inherently variable in different regions of the country --
socio-demographic differences matter.

Second, more
is more and less yields less -- the best care is the most comprehensive care,
and it costs more. Finally, poverty is expensive -- the greatest
"waste" is the necessary use of added resources when coping with
patients who are poor. If we want a technologically advanced, socially
equitable health-care system, we will have to organize our finances
accordingly. There is no quick fix. That's what we should be talking about. “

Reece Take

Four of the interrelated central themes in my book Obama, Doctors, and Health Reform are:

• One, the next big political health
care crisis will be lack of access to doctors. This will be aggravated by 78
million baby boomers entering Medicare in 2011 and a dramatic expansion caused
by millions of uninsured citizens entering the market.

• Two, the growing doctor shortage,
expected to peak at 150,000 to 200, 000 in a decade;

• Three, government policies that
systematically pay doctors less each year, this year scheduled to be a 20% cut;

• Four, doctors declining to accept
new Medicare patients because Medicare fees will make it difficult to maintain
and sustain practices.

Although incremental reform is essential and necessary, the health system is
too complex to reform, re-engineer, and overhaul in one fell swoop. Medicare is
not a good model on which to reform health care. For two reasons. It has no
cost controls. It is not representative of the system as a whole'

“As he raced through the U.S. Capitol this fall, Dr. Richard “Buz” Cooper, a
73-year-old University of Pennsylvania medical school professor, didn't mince
words. He denounced as “malarkey” a reigning premise of the health care debate
-- that one-third of the nation's $2.5 trillion in annual health spending is
unnecessary -- and said that the idea came from “a bunch of clowns.”

“The harsh language underscores Cooper's disdain for highly regarded work -- as
close to a sacred cow as anything in health care -- developed over two decades
by the Dartmouth Atlas of Health Care. The work by Dartmouth Medical School
researchers shows huge geographic variations in the amount of care that
hospitals and doctors provide, with spending in some areas running three times
as much as in others. Dartmouth argues much of the high spending is due to
extra procedures and tests that often don't help patients, but bring in more
money for doctors and hospitals.”

“The argument has been embraced by President Barack Obama's administration and
several lawmakers, who have repeatedly said that the nation could save as much
as $700 billion a year -- if only doctors and hospitals in high-spending areas,
such as Philadelphia, Los Angeles and Chicago, would end their profligate
practices and adopt the thriftier ways of say, the Geisinger Health Systems,
based in Danville, Pa. The House has inserted provisions in the health bill
that could punish high-spending hospitals in Philadelphia and elsewhere, while
rewarding low-spending facilities in places such as Albuquerque, N.M., Madison,
Wis., or Portland, Ore.”
The Poverty Factor

“But Cooper and some allies say that would be a disaster and hurt efforts by
doctors and hospitals to care for the poor. Cooper says the Dartmouth research
doesn't take into account the high cost of helping the impoverished, who often
spend more time in hospitals because they don't have people to care for them at
home and often return to the hospital when they can't afford needed
medications. “

“There is abundant evidence that poverty is strongly associated with poor
health status, greater per capita spending, more hospital readmissions and
poorer outcomes,” he wrote in an Oct. 24 post on his blog. “It is the single
strongest factor in variations in health care and the single greatest
contributor to 'excess' spending.”

How much of U.S. health spending is waste?

How much of this spending
is poverty-based?

The Dartmouth people says unwarranted waste is 30% of health care.
Cooper says caring for the poor is something hospitals have to bear.

Richard “Buz” Cooper, MD, now Co-Chair of the Council of Physician and Nurse
Shortages at the Leonard Davis Institute of Health Care Economics at the
University of Pennsylvania, and formerly Dean of the Medical School at the
University of Wisconsin at Milwaukee – gets it – in 2001 he and his colleagues
in Wisconsin wrote groundbreaking Health
Affairs article “Economic and Demographic Trends Signal an Impending
Physician Shortage.”

In it, they pointed out
experts misjudged such factors as America’s population explosion, economic
growth with discretionary income pouring into health care, desire for access to
specialist-oriented technologies, and created unprecedented demand were behind
the physician supply deficit.

Cooper said it was
simple: as the economy grows, the nation spends more money on health care.

Linda Aiken, PhD, professor of nursing at the University of Pennsylvania and
Cooper’s co-chair at the Council of Physician and Nurse Shortage gets it – she
says there is a double whammy because of a an accompanying shortage of nurses
of an even greater magnitude than the doctor shortage.

Cooper and Aiken believe in the next 15 years, there may be a 150,000 to
200,000 shortfall in doctors, and an 800,000 nursing shortage.

Where
Experts Go Awry

How could this be in a
nation of policy and health manpower “experts?”

The answer, according to Cooper, is two-fold:

• One, the experts simply
underestimated the dramatic increase in the U.S. population, our proclivity to
spend more on health care, our embrace of new technologies, and the capacity of
people in a democracy to get what they want.

• Two, the experts had flawed
mindsets.

Experts at the Council of Graduate Medical
Education, who determine the numbers of medical students and resident doctors,
and government policy wonks have long believed, wrongly, that we have too many
doctors, with more doctors we spend too much money, excess health care spending
is bad for the economy, we should organize and discipline physicians so we need
fewer doctors, not more;

If people would only
behave themselves, fewer doctors would be needed; and we make up doctors
shortages by substituting physician extenders for doctors.

Instead it turns out,
Americans want to see more doctors, not fewer, and health care is good for the
economy – a clean industry, a major employer, often the biggest industry in
town, and the only growth sector in the economy.

Policy wonks and federal policymakers don't get it. As result of their missed
estimates and flawed mindsets, federal wizards neglected the health care human
infrastructure by putting caps on the number of medical students and the number
of residency slots.

The problem with expert wizardry is that no matter what your scenario – more
efficient, higher quality care, and more federal money poured into care; or
more health insurance with expanded care; or more preventive counseling, more
information technologies, and more comprehensive, coordinated care, you need
more doctors.

What
Will Not Work

At this point, having existing doctors work harder will not work; nor will
persuading patients they should not have access to what they need or cannot
afford. Nor will turning over care to nurses, midwives, LPNs or orderlies. Nor
will redirecting care so doctors will be paid only within a federal system, in
other words, only reimbursing them if they see Medicare and Medicaid patients.

The
Problem

Well, what about single payer or Medicare for all? Here is Cooper’s response to
that solution.

The problem with Medicare for all is the Federal government runs Medicare.
It will sink health care. It is too capricious; it is too politically driven,
too bureaucratically onerous. Physicians hate Medicare. They like the
reimbursement when it comes, but it carries too much regulation, so much
inefficiency– caring for Medicare patients is a terribly inefficient process.
The view of the Federal government is that if they are paying the bills, they
should make a whole bunch of rules, well, that just doesn’t work.

They spend all their time
looking for the rotten apple in the barrel. There are rotten doctors, everybody
knows that. But good doctors are exposed to such scrutiny and such arbitrary
action; they are scared to death to take care of Medicare patients. So Medicare
for all, in my view, is the death of health care in America.
The Answer

The answer? Listen to the
people. Lighten up on federal rules. Lift the caps on the number of residency
programs and medical schools. Rebuild the nation’s physician and nurse
infrastructure.

The Health Reform Maze

Buy the Book

Book Description: In this first book in a series of four, Richard L. Reece, MD. provides a unique view of the roll out, and run up, of the Affordable Care Act. Reece shows in this book the progress and facets of ObamaCare's marketers and messengers, as the day approached for the launch of health insurance exchanges - the single most public and problematic portion of the new law. This is a must read for anyone who wants to chronicle this attempt to organize more than one-sixth of the U.S. economy by adding layers of federal government control and regulations.

Reece has been writing about U.S. health care for more than 45 years. His knowledge and experience, added to his keen intellect and gift of subtle humor, make this book a valuable part of anyone's collection.